The legal health record is generally used to respond to formal inquiries for evidentiary purposes. This does not affect the possibility of finding other information held by the organization. The move towards electronic health records complicates organizational efforts to define and disclose information. Many of the elements of the WASH have not been included in the statutory health record and data set planned in the past. Examples of documents and data that should be assessed for inclusion or exclusion include: The determining factor in determining whether the information should be considered part of the statutory health record is not where it is located or what format it takes, but how it is used and whether it can reasonably be expected to be included or excluded. that they are routinely released when a request for complete medical records is received. In addition to statistical reports, the nurse should write a monthly narrative report that provides an opportunity to present problems for administrative considerations. Health care organizations can take the following basic steps to eliminate confusion surrounding the legal health record and the overall record, as well as the disclosure of information from both: [The organization`s] policy is to maintain health records that are not compromised and to support [the organization`s] business and legal requirements. The use of information for commercial and legal purposes is usually, but not always, derived from the statutory health record. The most notable exceptions are disclosures for the purpose of disclosure or eDiscovery, where all information requested under the court order must be provided.
The second step is to determine whether the records are created in the normal course of the supplier`s or business` business. The source system or raw data is the data from which interpretations, summaries and annotations are derived. They may be referred to as part of the statutory health record, whether they are integrated into a single system or stored as part of the source system. Purpose: This policy identifies [the organization`s] integrity records for business and legal purposes and to ensure that the integrity of the integrity record is maintained to meet operational and legal requirements. The following definitions may be useful to organizations when creating the legal health record and defining record group policies. All key terms identified by the organization must also be included in the organization`s final policy. Scope: This directive applies to all uses and disclosures of the medical record for administrative, commercial or evidentiary purposes. It includes records that can be held in a variety of media, including but not limited to electronic, paper, digital images, video, and audio. It excludes medical records that are not normally created and maintained in the ordinary course of [the organization`s] business. Business documents: “A document/record created or received for commercial purposes and retained as evidence or because the information has value. Because this information is created, received and retained by an organization or individual in accordance with its legal obligations or in the course of its activities as evidence and information, it must always provide a complete and accurate record, free of gaps or additions.
`1 Note: Documentation of the results may be indicated in the patient`s medical record. Other legal privileges may apply to these documents. It helps guide staff and students – when scheduled recordings are used as an assessment tool during conferences. Legal Health Record: AHIMA defines statutory health record as “generated by or for a healthcare organization as a business record” and is the record published upon request. This does not affect the possibility of finding other information held by the organization. The custodian of the legal health record is the person responsible for health information in collaboration with IT staff. HIM experts oversee the operational functions related to the collection, protection and archiving of the statutory health record, while IT staff manage the technical infrastructure of the electronic health record. “6 Organizations should follow the following common principles when determining their medical records and statutory record sets. In addition to the HIPAA privacy rule, other federal laws and regulations give individuals the right to access their health information. Organizations must comply with these obligations and protect the confidentiality of patient records by ensuring that they are accessible only to authorized individuals.
Business partner records that match the definition of a specific record, but only duplicate information managed by the covered entity Derived or administrative data are derived from the primary health record and contain selected data elements that support the provision, support, assessment, or advancement of patient care. Data and derived documents should be given the same level of confidentiality as the legal medical record. However, derived data should not be considered part of the medical record and would not be submitted in response to a court order, subpoena or health record request. In addition, the type of medium on which information is stored is also expanding. Source recordings can include diagnostic images, videos, voice files, and emails. The organization must determine which of these data elements, electronically structured documents, images, audio files, and video files should be included. There may be times when an individual has a legitimate need to access source data that is not considered part of the health record or the record established by law. The organization`s legal counsel should advise in case of uncertainty. Appendix E contains policy definitions that may be included in corporate policies.
Appendix F contains an example template for the statutory health record and Appendix G provides an example template for a particular policy on a group of records. Records from source systems may be considered part of the legal health record based on the contents of the source system record. Historically, reports or conclusions on which clinical decision-making is based are part of the legal health record.
